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FORM 4A : FAMILY IDENTITY CARD

Regulation 95A

Insurance No.........................................

Name of insured person..................................................

Sex..................................

Son/daughter/wife of.................................................

Address..........................................................................................................................................

Dispensary.............................................................................................

PARTICULARS OF MEMBERS OF FAMILY

Sl. No.

Name

Date of birth

Relationship with the insured person

Identification marks

1

 

 

 

 

2

 

 

 

 

Prepared by:

Signature or thumb-impression of the insured person

 

 

 

 

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